Neonatal Respiratory Nursing Guide — RDS, Surfactant & Respiratory Support

Tab 1

Neonatal Respiratory Assessment

Normal values, signs of distress, Silverman-Anderson scoring, and key neonatal respiratory conditions.

Normal Values

Respiratory Rate & SpO2

Normal RR: 40–60 breaths/min
Tachypnoea: >60 breaths/min
Pre-ductal SpO2 target (preterm): 91–95%
SpO2 target (term): >95%
Pre-ductal probe site: right hand
Hyperoxia risk in preterm: ROP (retinopathy of prematurity)

Clinical Signs

Signs of Respiratory Distress

Tachypnoea (>60 breaths/min)
Grunting — auto-PEEP mechanism, laryngeal closure
Nasal flaring — accessory muscle use
Subcostal / intercostal recession
Head bobbing — sternocleidomastoid use
Central cyanosis — late and serious sign

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Silverman-Anderson Respiratory Distress Score

5-component scoring tool — 0 (no distress) to 10 (maximum distress)

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Component	Score 0	Score 1	Score 2
Upper chest movement	Synchronised with abdomen	Lag on inspiration	See-saw (paradoxical)
Lower chest retraction	No retraction	Just visible	Marked retraction
Xiphoid retraction	None	Just visible	Marked
Nasal flaring	None	Minimal	Marked
Expiratory grunt	None	Audible with stethoscope	Audible without stethoscope

Interpretation: 0 = No distress | 1–3 = Mild | 4–6 = Moderate | 7–10 = Severe distress requiring urgent escalation.

Nursing tip: Score at rest, not during crying. Document baseline and trend over time. Escalate any score ≥4 promptly.

Key Neonatal Respiratory Conditions

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Respiratory Distress Syndrome (RDS)

Surfactant deficiency — most common in preterm <32 weeks

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RDS results from surfactant deficiency in premature lungs. Without surfactant, surface tension rises causing progressive alveolar collapse (atelectasis) on each expiration. The infant works increasingly hard to re-inflate collapsed alveoli.

Onset: within hours of birth in preterm neonates
CXR: ground-glass appearance, air bronchograms, low lung volumes
Presentation: tachypnoea, grunting, recession, cyanosis escalating over first 48–72 hours
Antenatal steroids (betamethasone) accelerate surfactant production — standard care
Treatment: surfactant replacement + respiratory support (CPAP or ventilation)

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Transient Tachypnoea of Newborn (TTN)

Retained foetal lung fluid — self-resolving in 24–72 hours

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TTN is caused by delayed reabsorption of foetal lung fluid. The foetal lung contains fluid that is normally cleared during vaginal birth (thoracic compression) and by adrenaline-stimulated sodium channels. Caesarean section delivery bypasses this mechanism.

Common after elective CS, late preterm (34–37 weeks), or macrosomic infants
CXR: perihilar streaking, fluid in fissures, "wet lung", mild cardiomegaly
Self-resolves in 24–72 hours with supportive care
Treatment: supplemental oxygen (usually low FiO2), monitoring — rarely needs CPAP
Key distinction from RDS: term/late-preterm infant, improving trend within 12–24h

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Meconium Aspiration Syndrome (MAS)

Chemical pneumonitis, air trapping, pulmonary hypertension

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Thick meconium in amniotic fluid, when aspirated before or during birth, causes a chemical pneumonitis, mechanical airway obstruction (ball-valve — air trapping), and can trigger PPHN due to pulmonary vasoconstriction.

Risk factors: post-term pregnancy, foetal distress, thin vs thick meconium distinction
CXR: hyperinflation, patchy infiltrates, pneumothorax risk (air trapping)
Complications: PPHN, air-leak syndrome (pneumothorax, pulmonary interstitial emphysema)
Management: ventilatory support, avoid high pressures, surfactant in some centres
Routine tracheal suctioning at delivery no longer recommended (NRP 2015+) unless depressed infant

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Persistent Pulmonary Hypertension of Newborn (PPHN)

Failed postnatal pulmonary vasodilation — right-to-left shunting

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In PPHN, pulmonary vascular resistance fails to fall after birth. High pulmonary pressure causes right-to-left shunting of blood through the patent foramen ovale (PFO) and patent ductus arteriosus (PDA), bypassing the lungs — leading to severe hypoxaemia refractory to oxygen.

Classic sign: differential cyanosis — pre-ductal SpO2 (right hand) >10% higher than post-ductal (foot)
Causes: MAS, RDS, birth asphyxia, idiopathic, diaphragmatic hernia
Diagnosis confirmed by echocardiography
Triggers that worsen PPHN: hypoxia, acidosis, hypothermia, pain, agitation
Treatment: optimise oxygenation, iNO, sildenafil, ECMO in refractory cases

Tab 2

Surfactant Therapy Nursing

Indications, types, administration techniques (INSURE & LISA/MIST), and post-surfactant monitoring.

Physiology

What Surfactant Does

Reduces alveolar surface tension at the air-liquid interface
Prevents alveolar collapse on expiration (maintains FRC)
Produced by type II pneumocytes — mature by 34–36 weeks gestation
Deficiency → progressive atelectasis → ventilation/perfusion mismatch
Exogenous surfactant replaces or supplements endogenous supply

Indications

When to Give Surfactant

RDS in preterm <32 weeks — prophylactic (in delivery room) or rescue
Rescue: FiO2 >0.3–0.4 on CPAP 6 cmH2O in preterm
Severe RDS in term neonates (less common)
MAS in some centres (off-label, variable evidence)
Do not delay in deteriorating infant — early rescue superior to late rescue

Preparations

Surfactant Types

Poractant alfa (Curosurf) — porcine derived, high phospholipid concentration
Beractant (Survanta) — bovine derived
Calfactant (Infasurf) — bovine lung lavage
All require refrigeration; warm to body temperature before use
Gentle inversion to mix — do NOT shake vigorously

Administration Techniques

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INSURE Technique

Intubate – Surfactant – Extubate to CPAP

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INSURE involves brief intubation solely for surfactant delivery, followed by prompt extubation back to non-invasive respiratory support (CPAP). This reduces exposure to invasive ventilation and its complications.

Pre-medicate: consider atropine (0.01–0.02 mg/kg) and short-acting sedation/analgesia (morphine, fentanyl)
Confirm ET tube position: lip mark, bilateral air entry, CXR if time allows
Administer surfactant as slow bolus via ET tube — may divide into 2–4 aliquots
Position changes (head turn left/right) only if INSURE protocol requires
Extubate promptly once surfactant given and infant breathing spontaneously
Return to CPAP 5–6 cmH2O — wean FiO2 quickly as oxygenation improves

Nursing role: Prepare equipment, assist with intubation, manage airway, monitor HR and SpO2 throughout, document lip mark and tube size, support prompt extubation.

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LISA / MIST Technique

Less Invasive Surfactant Administration — avoids intubation entirely

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LISA (Less Invasive Surfactant Administration) / MIST (Minimally Invasive Surfactant Therapy) delivers surfactant via a thin catheter (e.g., 5Fr feeding tube or proprietary catheter) passed into the trachea under direct laryngoscopy while the infant remains on CPAP and breathing spontaneously. No positive pressure ventilation is applied.

Infant remains on CPAP — maintains spontaneous breathing throughout
Thin catheter passed through vocal cords under laryngoscopy
Surfactant administered slowly over 1–2 minutes
No sedation or minimal premedication — infant must be breathing
Evidence: fewer days of ventilation, less BPD, better neurological outcomes vs INSURE in some trials
May cause transient bradycardia/SpO2 drop — atropine at bedside, CPAP support immediately after

Nursing role: Maintain CPAP during procedure, have resuscitation equipment ready, monitor HR and SpO2 continuously, document time and volume administered.

Post-Surfactant Monitoring

Immediate (0–60 min)

Rapid Oxygenation Response

Expect rapid improvement in SpO2 and FiO2 requirement
Reduce FiO2 promptly — hyperoxia causes ROP and lung injury
Watch for rebound bradycardia or desaturation immediately post-administration
Assess for reflux of surfactant — reposition if needed
Check bilateral air entry post-intubation (INSURE) before extubating

Complications

Surfactant Complications

Transient bradycardia during administration
Transient desaturation — manage with brief BVM if on INSURE
Surfactant reflux into ET tube or pharynx
Pneumothorax — from uneven distribution or over-distension
Pulmonary haemorrhage — rare, associated with PDA and surfactant

Ongoing Care

Post-Dose Nursing

Avoid chest physiotherapy for 1–2 hours post-surfactant
Repeat dose may be needed (q12h) if FiO2 remains >0.3 on CPAP
Document: dose (mg/kg), lot number, route, time, response
Monitor blood gas 30–60 min post-dose
Minimum handling protocol immediately post-surfactant

Tab 3

CPAP & High-Flow Nasal Cannula (HFNC) Nursing

Non-invasive respiratory support — device selection, setup, monitoring, weaning, and skin protection.

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Nasal CPAP (nCPAP) — Mechanism & Setup

Continuous positive end-expiratory pressure prevents alveolar collapse

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nCPAP delivers a continuous positive pressure to the airway, maintaining positive end-expiratory pressure (PEEP) throughout the respiratory cycle. This prevents alveolar collapse at end-expiration, maintaining functional residual capacity (FRC).

Bubble CPAP — gas bubbles through underwater seal; simple, cost-effective, wide GCC use
Ventilator-driven CPAP — precise pressure delivery, integrated monitoring
Infant Flow Driver — fluidic flip mechanism; reduces work of breathing
Starting pressure: 5–8 cmH2O (typically 5–6 in first instance)
Starting FiO2: titrate to achieve SpO2 91–95% (preterm) or >95% (term)

Interface: Binasal prongs preferred over single prong or mask — better seal, less leak. Size: prongs should fill nares without blanching.

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CPAP Nursing Care

Positioning, NGT, interface management, securing

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NGT essential: CPAP causes aerophagia and gastric distension — insert NGT (open to air or on free drainage) in all CPAP infants
Head positioning: neutral or slightly extended ("sniffing" position) — avoid flexion or hyperextension
Hat/bonnet for securing interface — avoid pressure on fontanelle
Document CPAP pressure, FiO2, SpO2, RR, work of breathing q2h minimum
Check water level in bubble CPAP chamber hourly
Ensure humidification — heated humidified circuits prevent mucosal drying

CPAP troubleshooting: Increasing FiO2 requirement → check for leak, blockage, wrong prong size, gastric distension, or true clinical deterioration. Escalate if FiO2 >0.4.

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CPAP Weaning

Stepwise pressure reduction when clinically stable

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Criteria to begin wean: SpO2 stable on FiO2 <0.30, minimal work of breathing, no apnoeas
Reduce CPAP pressure by 1 cmH2O steps — allow 12–24 hours at each step
Wean to 4 cmH2O before trialling off — do not remove abruptly
Consider HFNC as step-down from CPAP
Failed CPAP wean: increasing FiO2, increasing apnoea frequency, WOB worsening — return to previous pressure

High-Flow Nasal Cannula (HFNC)

HFNC Mechanism

Heated Humidified High-Flow

Delivers heated, humidified gas at flows >1 L/min via nasal cannula
Generates variable positive pressure (depends on flow and infant size)
Starting dose: 2 L/kg/min (range 1–8 L/min)
Less effective than CPAP for primary RDS management
Advantages: easier to nurse, more comfortable, less facial trauma, less sedation needed

HFNC Nursing

Setup & Monitoring

Cannula size: should not occlude >50% of nostril diameter
Ensure heated humidification circuit — high flow without humidity causes mucosal damage
NGT recommended for same reasons as CPAP
Monitor SpO2 and work of breathing — reassess at 2–4 hours
Failure criteria: FiO2 >0.4, increasing WOB, apnoea — escalate to CPAP

Skin Protection

Interface Skin Care

2-hourly interface checks — nasal septum most vulnerable
Hydrocolloid bridges/dressings for nasal septum protection
Rotate between prong and mask interfaces if possible to redistribute pressure
Remove and assess skin q4h minimum — document any redness/breakdown
Nasal septal injury: change to mask CPAP, escalate skin care plan

Tab 4

Mechanical Ventilation in Neonates

Indications, modes, lung-protective strategies, HFOV, blood gas monitoring, sedation, and ET tube care.

Indications

When to Intubate & Ventilate

Failure of nCPAP: FiO2 >0.4–0.5 with increasing WOB on CPAP 8 cmH2O
Apnoea unresponsive to caffeine citrate therapy
Severe PPHN requiring high FiO2 and iNO
Cardiovascular instability, shock
Prematurity <27 weeks — may require elective intubation for surfactant delivery

Ventilator Modes

Common Neonatal Modes

SIMV — synchronised intermittent mandatory ventilation; infant can breathe between set breaths
PSV — pressure support ventilation; supports every spontaneous breath
HFOV — high-frequency oscillation; very small tidal volumes at high frequency
Volume-targeted ventilation (VTV): set tidal volume 4–6 ml/kg — reduces volutrauma

Lung Protection

Lung-Protective Strategy

Target tidal volume: 4–6 ml/kg
Permissive hypercapnia: target pH >7.25, PaCO2 5–8 kPa (45–60 mmHg)
Adequate PEEP (4–6 cmH2O) to prevent derecruitment
Avoid peak inspiratory pressure >20–25 cmH2O when possible
Goal: minimise ventilator-induced lung injury (VILI) and BPD risk

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High-Frequency Oscillatory Ventilation (HFOV)

MAP, amplitude (ΔP), frequency (Hz) — chest wiggle assessment

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HFOV delivers very small tidal volumes (often sub-anatomical dead space) at frequencies of 5–15 Hz. Gas exchange occurs through mechanisms including asymmetric velocity profiles and molecular diffusion rather than bulk flow.

MAP (Mean Airway Pressure): controls oxygenation — set 1–2 cmH2O above conventional ventilator MAP
Amplitude (ΔP): controls CO2 elimination — assess chest wiggle (should see chest vibration to groin)
Frequency (Hz): typically 10–15 Hz for preterm, 8–12 Hz for term — higher frequency = less CO2 removal
Chest wiggle factor: visible vibration from chest to groin = adequate amplitude
Nursing: do not disconnect for suctioning (in-line suction preferred), assess CXR for lung volume (aim 8–9 rib expansion)

Remember: On HFOV, increasing frequency reduces CO2 removal (counterintuitive). Increasing amplitude increases CO2 removal.

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Blood Gas Monitoring

Frequency, sample handling, ABG vs CBG interpretation

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Initial frequency: q4h when on ventilation, or after any ventilator change
Stable ventilated infant: q8–12h
Anaerobic sample handling: cap syringe immediately, transport on ice, process within 15 minutes
ABG (arterial): from UAC or radial/temporal artery; gold standard — gives PaO2
CBG (capillary): heel prick; reliable for pH, CO2, HCO3 — PO2 underestimated, NOT used for oxygenation targets
Pre-warm heel for capillary sample (warm pack x5 min) — improves arterialization

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Sedation & Analgesia on Ventilator

Morphine, midazolam, neuromuscular blockade

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Morphine infusion: 0.01–0.05 mg/kg/hr — commonly used for ventilated preterm infants
Fentanyl: 0.5–2 mcg/kg/hr — shorter acting, useful during procedures
Midazolam: 0.01–0.06 mg/kg/hr — caution in preterm (adverse neurodevelopmental outcomes reported)
Neuromuscular blockade (e.g., vecuronium): rarely used, avoided in premature infants — associated with worse outcomes
Sucrose (24%) for procedural pain — evidence-based, non-pharmacological
Pain assessment: PIPP (Premature Infant Pain Profile), NIPS — use validated tools

Clinical note: Avoid routine morphine infusions in spontaneously breathing preterm infants on CPAP — increases apnoea risk.

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ET Tube Care

Position, securing, suction, extubation readiness

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Document lip mark at each nursing assessment — note at intubation and after taping
CXR to confirm ET tube tip at T2–T3 (midway between vocal cords and carina)
Secure taping: use hydrocolloid base, document tape change frequency
Suction frequency: q4–8h or as clinically indicated (increased secretions, desaturation, rising pressures)
Suction technique: closed in-line for HFOV; limit suction depth to ETT tip + 0.5 cm
Extubation readiness: weaning pressures (PIP <14, PEEP 4, rate ≤20), good spontaneous effort, adequate blood gas, caffeine on board

Post-extubation: Place immediately on CPAP or HFNC. Have PEEP bag/resuscitation equipment at bedside. Reassess at 1–2 hours.

Tab 5

PPHN & Inhaled Nitric Oxide (iNO) Nursing

Pathophysiology, differential cyanosis, iNO delivery, methhaemoglobin monitoring, weaning, and ECMO criteria.

Pathophysiology

PPHN Mechanism

Failure of normal postnatal pulmonary vascular resistance drop
High PVR → right-to-left shunting through PFO and PDA
Blood bypasses the lungs → severe refractory hypoxaemia
Classic sign: pre-ductal SpO2 (right hand) > post-ductal (foot) by >10%
Echo confirms: TR jet velocity, ductal flow direction (R→L), septal bowing

Differential SpO2

Pre- vs Post-Ductal Monitoring

Pre-ductal site: right hand (right radial pulse probe)
Post-ductal sites: either foot (left or right)
Significant difference: >10% SpO2 gap = R-to-L ductal shunting
Both probes should be in place simultaneously for real-time comparison
Document both readings q1h in acute PPHN — wider gap = worsening shunt

Triggers to Avoid

PVR-Increasing Factors

Hypoxia — maintain pre-ductal SpO2 >95% in term PPHN
Acidosis — target pH >7.35 (avoid respiratory and metabolic acidosis)
Hypothermia — maintain normothermia 36.5–37.5°C
Pain / agitation — adequate analgesia and sedation essential
Hypocapnia — avoids cerebral vasoconstriction; target PaCO2 40–45 mmHg

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Inhaled Nitric Oxide (iNO) Nursing

20 ppm starting dose — delivery system, methhaemoglobin monitoring, circuit management

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iNO is a selective pulmonary vasodilator. It diffuses into smooth muscle of pulmonary arterioles, activates cGMP, and causes vasodilation. Because it is immediately inactivated by haemoglobin, systemic effects are minimal.

Starting dose: 20 ppm — this is the evidence-based starting dose for PPHN in term neonates
Delivery: via dedicated iNO delivery system integrated into ventilator circuit
Never administer without calibrated delivery device — manual boluses dangerous
Positive response: SpO2 improvement >20 points and/or FiO2 reduction within 30 minutes
Non-responders (<10% improvement): consider ECMO evaluation
Methaemoglobin monitoring: check q4h — alert level >2.5%; >5% treat with methylene blue
NO2 monitoring: keep <3 ppm (converted from NO in circuit)

Never abruptly stop iNO — rebound pulmonary hypertension can cause acute life-threatening deterioration. Must wean gradually (20 → 10 → 5 → 1 ppm over hours to days).

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iNO Weaning Protocol

Gradual stepwise wean — avoid rebound PPHN

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Begin wean when: FiO2 <0.6, sustained improvement in oxygenation over 4+ hours
Wean steps: 20 → 10 → 5 → 1 ppm — minimum 4 hours at each step
Trial off at 1 ppm: if SpO2 remains stable, discontinue
Rebound PPHN signs on wean: sudden SpO2 drop, widening pre/post-ductal difference — return to previous dose
If unable to wean from 5 ppm after 48–72h: echocardiographic assessment, consider sildenafil

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Sildenafil & ECMO for Refractory PPHN

Adjunct pulmonary vasodilation — ECMO criteria and transfer

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Sildenafil: PDE-5 inhibitor — oral or IV; used when iNO unavailable or as adjunct; 0.5–2 mg/kg/dose q6–12h (oral)
Sildenafil as transition agent when weaning from iNO to prevent rebound
ECMO criteria (Oxygenation Index): OI >40 on maximal management on two consecutive blood gases
OI formula: (FiO2 × MAP × 100) / PaO2
ECMO centres in GCC: limited — early contact with ECMO centre essential; consider transfer before OI >40
Nursing pre-ECMO: maintain normothermia, blood products available, family communication, documentation

Echo-guided management: Regular echocardiography guides therapy — tricuspid regurgitation jet velocity (TRJV), ductal shunt direction, septal position, and biventricular function all inform escalation/de-escalation.

Tab 6

GCC Exam Focus & Quick Reference

DHA / DOH / SCFHS / QCHP high-yield points, comparison tables, CPAP troubleshooting, and exam-format summaries.

Silverman-Anderson Respiratory Distress Score Calculator

Adjust each component slider (0–2) to calculate total score, severity, and management guidance.

1. Upper chest movement

0 — Synchronised1 — Lag2 — See-saw

2. Lower chest retraction

0 — None1 — Just visible2 — Marked

3. Xiphoid retraction

0 — None1 — Just visible2 — Marked

4. Nasal flaring

0 — None1 — Minimal2 — Marked

5. Expiratory grunt

0 — None1 — Stethoscope only2 — Audible

Silverman-Anderson Score (0–10)

Severity

No Distress

SpO2 Target

Preterm: 91–95% | Term: >95%

Recommended Management

Observe, routine care, continuous SpO2 monitoring

FiO2 Alert: If FiO2 >0.4 is needed to maintain SpO2 targets, consider escalation to nCPAP or mechanical ventilation. Review immediately.

RDS vs TTN vs MAS — Comparison Table Exam Favourite

Feature	RDS	TTN	MAS
Gestation	Preterm (<32–35 wks typical)	Late preterm or term	Term or post-term
Cause	Surfactant deficiency	Retained foetal lung fluid	Meconium aspiration
Onset	Birth / within hours	Birth / within hours	Birth
Course	Worsens 48–72h, improves day 3–5	Improves 24–72h	Variable, may worsen
CXR	Ground-glass, air bronchograms, low volume	Perihilar streaking, fluid in fissures	Hyperinflation, patchy infiltrates
Treatment	Surfactant + CPAP/ventilation	Oxygen support only, usually resolves	Ventilation, surfactant (some), iNO if PPHN
PPHN risk	Low–moderate	Low	High
Surfactant	Yes — primary treatment	No	Selected cases

CPAP Troubleshooting Quick Reference Nursing Practical

Problem	Possible Cause	Nursing Action
Rising FiO2 requirement	Leak, wrong prong size, clinical deterioration, gastric distension	Check interface seal, measure nares, aspirate NGT, assess clinically
Gastric distension	CPAP swallowed air without NGT	Insert NGT, leave open to air, aspirate
Nasal blanching / breakdown	Prolonged prong pressure on septum	Apply hydrocolloid bridge, switch to mask, document
Bradycardia / desaturation	Airway secretions, displacement, apnoea	Stimulate, suction if secretions, check prong position, escalate if no response
No bubbling in bubble CPAP	Low water level, circuit disconnect	Check water level (refill), check all connections, verify CPAP pressure
Increased work of breathing on CPAP	CPAP failure, pneumothorax, infection	Assess urgently, transilluminate chest, CXR, consider intubation

DHA / DOH / SCFHS / QCHP High-Yield Questions

Silverman-Anderson Score

Key Exam Points

5 components — max 2 each = score 0–10
Score 0 = no distress; 7–10 = severe
Grunting = auto-PEEP via laryngeal braking
Score at rest, not during crying
Used to guide escalation of respiratory support

RDS Nursing Essentials

Key Exam Points

Surfactant: warm to body temp, gentle inversion
INSURE = Intubate-Surfactant-Extubate to CPAP
LISA: no intubation, infant stays on CPAP
After surfactant: reduce FiO2 promptly (ROP risk)
No chest physio for 1–2 hours post-surfactant

CPAP Nursing

Key Exam Points

Starting CPAP: 5–8 cmH2O
NGT mandatory — prevents gastric distension
Binasal prongs preferred over single prong
Wean when FiO2 <0.30 and SpO2 stable
Skin checks q2h, hydrocolloid bridges

PPHN & iNO

Key Exam Points

Differential cyanosis: pre-ductal SpO2 > post-ductal
Pre-ductal = RIGHT HAND (not left)
>10% difference = significant R-to-L shunt
iNO starting dose = 20 ppm
Methaemoglobin: check q4h — alert at >2.5%
Never stop iNO abruptly — rebound PPHN
ECMO criteria: OI >40 on maximal management

Neonatal Ventilation

Key Exam Points

Lung-protective TV: 4–6 ml/kg
HFOV: amplitude controls CO2 (not frequency)
Permissive hypercapnia: pH >7.25, CO2 5–8 kPa
Morphine infusion: 0.01–0.05 mg/kg/hr
CBG: not for oxygenation — use PaO2 from ABG

SpO2 Targets

Key Exam Points

Preterm: pre-ductal SpO2 91–95%
Term: SpO2 >95%
Hyperoxia risk: ROP (retinopathy of prematurity)
Post-surfactant: wean FiO2 aggressively
PPHN term: maintain pre-ductal SpO2 >95%